DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

 

Complaint Case No : CC/141/2021

Date of Institution : 22.07.2021

Date of Decision : 27.01.2023

Rajiv Kumar son of Late Sh. Mohinder Kumar resident of House No. 172, Astha Enclave, Dhanaula Road, Near Electricity Board, Barnala, Tehsil and District Barnala.    

…Complainant

Versus

1. Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited), Regd. Office 5th Floor, 19 Chawla House, Nehru Place, New Delhi-110019 through its Managing Director/ Chairman/Authorized Signatory. 

2. Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited), Corporate Office: Unit No. 604-607, 6th Floor, Tower C, Unitech Cyber Park, Sector 39, Gurugram-122001 (Haryana) through its Managing Director/Chairman/Authorized Signatory. 

3. Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited), Vipul Tech Square, Tower C, 3rd Floor, Sector-43, Golf Course Road, Gurgaon-122009 through its Managing Director/Chairman/Authorized Signatory.

4. Medanta Hospital, Sector 38, Gurugram, Haryana-122001 through its Chairman/Managing Director/Authorized Signatory.

5. Medanta Hospital, Regd. Office Global Health Private Limited, E-18, Defence Colony, New Delhi-110024, India through its Chairman/ Managing Director/Authorized Signatory.

6. Yogesh Jindal, Jindal Pollution Check Centre, Opposite Court Complex, Barnala, Authorized Agent, Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited).

…Opposite Parties

Complaint under The Consumer Protection Act.

Present: Sh. Rajan Chaudhary Adv counsel for complainant.

Sh. Dhiraj Kumar Adv counsel for opposite parties No. 1 

to 3.

Opposite parties No. 4 and 5 deleted.

Opposite party No. 6 exparte.

Quorum.-

1. Sh. Ashish Kumar Grover : President

2. Smt. Urmila Kumari : Member

3. Sh. Navdeep Kumar Garg : Member

(ORDER BY ASHISH KUMAR GROVER PRESIDENT):

    The complainant Rajiv Kumar filed the present complaint under the Consumer Protection Act against Care Health Insurance Limited, New Delhi and others. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that the complainant was insured with the opposite party No. 1 to 3 by way of Health Insurance policy for Rs. 5 lacs vide policy No. 11680988 bearing client ID 57511557 for the period from 14.10.2017 to 13.10.2019 and thereafter from 14.10.2019 to 13.10.2021 and premium of Rs. 36,021/- was charged from the complainant and complainant deposited the premium amount through opposite party No. 6 at Barnala.  

3. It is further alleged that the complainant fell ill and was taken to Medanta Hospital Gurugram on 17.2.2021 and was got admitted on 10.3.2021. The doctor conducted various test and after arranging implants conducted surgery on 11.3.2021. The complainant was discharged on 20.3.2021 and total expenditure on the treatment was Rs. 6,96,908/-. It is further alleged that due intimation of the claim was given to the opposite parties for availing cashless treatment but the complainant did not receive any approval from the opposite parties No. 1 to 3 and amount of treatment was paid by the complainant himself. It is further alleged that the complainant was shocked to receive a letter dated 3.5.2021 from the opposite parties No. 1 to 3 stating that the claim of the complainant was not payable as per policy terms and conditions lister as Permanent Exclusion-Condition cause by Suicide or Substance abuse, Permanent Exclusion, the only ground given in the repudiation letter. The opposite parties had given false reason behind the repudiation of the claim of the complainant, which amounts to deficiency in service and unfair trade practice. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties may be directed to pay the claim amount of Rs. 5 lacs only the amount of insurance alongwith interest at the rate of 12% per annum from the date of filing of claim till realization.

2) To pay Rs. 50,000/- on account of compensation for mental agony and harassment and Rs. 11,000/- as litigation expenses. 

3) Any other fit relief may also be given. 

4. Upon notice of this complaint, opposite parties No. 1 to 3 filed written version taking preliminary objections that the present complaint is not maintainable as the complaint involves disputed question of facts which cannot be determined in summary jurisdiction of this Commission. As per Section 2 (1) (d) of the Insurance Regulatory and Development Authority, proposal form means a from to be filled in by the proposer for insurance, for furnishing all material information required by the insurer in respect of risk, in order to enable the insurer to decide whether to accept or decline, to undertake the risk and in the event of acceptance of the risk to determine the rates, terms and conditions of a cover to be granted. Further, as per Section 11 of the Insurance Act, 1938 the policyholder shall furnish all information that is sought from him by the insurer and also any other information which the insurer considers as having a bearing on the risk to enable the latter to assess properly the risk sought to be covered by a policy. Thus it is evident that Act and regulations framed thereunder imposes a duty upon the policyholder to disclose all the material facts to the insurer to enable them to assess the risk to be undertaken. The intricate questions of law and facts are involved in this case and parties have to lead their evidence by examining the witnesses. The procedure under the Act is summary in nature and complainant if so advised may file civil suit seeking the alleged relief. The complainant himself committed breach of the terms and conditions of the policy so the claim of the complainant stands declined as permanent exclusion condition caused by suicide or substance abuse and there is no deficiency in service on the part of the answering opposite party.

5. The answering opposite party issued a health insurance policy of Product Care vide policy No. 11680988 issued to the complainant with effect from 4.10.2017 to 13.10.2019. The policy has been further renewed from 14.10.2019 to 13.10.2021. The complainant alongwith his spouse and children are covered under the policy for a sum assured of Rs. 5,00,000/- subject to policy terms and conditions. The copy of schedule bearing relevant details of the policy alongwith policy bond having terms and conditions were duly supplied to the proposer. No assurance was given to the complainant beyond the terms and conditions of the policy. The complainant never approached the answering opposite party stating that any information given in the policy schedule was incorrect. The complainant through its treating hospital approached the answering opposite party with a cashless request on 10.3.2021 pursuant to complainant treatment at Medanta The Medicity Gurugram wherein he was treated for carcinoma lower alveolus. Upon receipt of cashless request the answering opposite party sought certain additional information from the hospital vide query dated 10.3.2021. The opposite party made a claim investigation basis the documents submitted along the claim form and investigation, it came to light that the complainant has been taking tobacco and alcohol since past 4 years as per the statement of relative of complainant Mr. Bimal Kumar. The ailment of complainant has direct correlation with his habit of tobacco intake. So, the cashless request was denied by the opposite party vide denial letter dated 11.3.2021. After that opposite party received the reimbursement claim vide claim No. 91673167 for an amount of Rs. 6,96,908/- on 28.4.2021. The complainant was admitted from 10.3.2021 till 20.3.2021 at Medanta where he was treated for carcinoma lower alveolus. The reimbursement of the claim of the complainant was rejected on the same ground vide letter dated 3.5.2021 as per policy terms and conditions. The letter stated rejection reason as permanent exclusion-condition caused by suicide or substance abuse. Permanent exclusion.- Any claim in respect of any insured person for arising out of or directly or indirectly due to any of the following shall not be admissible unless expressly stated to the contrary elsewhere in the policy terms and conditions. Act of self-destruction or self inflicted injury, attempted suicide or suicide while sane or insane or Illness or Injury attributable to consumption, use, misuse or abuse of intoxicating drugs, alcohol or hallucinogens. So, the complaint is not maintainable as complainant himself violated the terms and conditions of the policy and there is no deficiency in service on the part of the answering opposite party. The insurance company cannot do injustice to genuine policyholders by allowing inadmissible claims.

6. On merits, it is submitted that the complainant himself approached the adviser of the opposite party to purchase the Health Insurance and got entire information and after satisfy with the same only then he paid the premium against the policy and answering opposite party issued the policy as per provisions of insurance law. Rest of the submissions already mentioned in the preliminary objections of the written version so there is no need to reiterate the same. However, it is submitted that the opposite party provides its best services to the complainant so there is no deficiency in service or unfair trade practice on their part. Lastly the opposite parties No. 1 to 3 prayed for the dismissal of the present complaint with costs. 

7. The opposite parties No. 4 and 5 were deleted from the arena of the opposite parties vide order dated 28.7.2021 and opposite party No. 6 preferred to remain exparte. 

8. The complainant filed rejoinder to the written version of the opposite parties No. 1 to 3 and denied all the averments mentioned by the opposite parties No. 1 to 3 in their written version. 

9. In support of his complaint, the complainant tendered into evidence his own affidavit Ex.C-1, copy of policy Ex.C-2, copy of treatment chart/report dated 17.2.2021 Ex.C-3, copy of medical record Ex.C-4, copy of discharge summary Ex.C-5, copy of claim form Ex.C-6, copy of claim denial letter Ex.C-7, copies of bills Ex.C-8, copies of receipts and bills Ex.C-9 to Ex.C-13, copy of generic notes Ex.C-14, copy of report dated 5.10.2020 Ex.C-15, copy of out patient summary  Ex.C-16 and closed the evidence. 

10. To rebut the case of the complainant the opposite parties No. 1 to 3 tendered in evidence affidavit of Shreya Chansoria Ex.OP-1.2.3/1, copy of policy Ex.OP-1.2.3/2, copy of deficiency letter Ex.OP-1.2.3/3, copy of statement Ex.OP-1.2.3/4, copy of denial letter Ex.OP-1.2.3/5, copy of claim denial letter Ex.OP-1.2.3/6 and closed the evidence.    

11. We have heard the learned counsel for the parties and have gone through the record on the file. Written arguments also filed by the appearing parties. 

12. The complainant alleged that the complainant has obtained the Health Insurance Policy for Rs. 5 lacs bearing policy No. 11680988 Client ID 57511557 for the period from 14.10.2017 to 13.10.2019 and thereafter he renewed the said policy from 14.10.2019 to 13.10.2021. It is further alleged by the complainant that complainant fell ill and got admitted in Medanta Hospital, Gurugram and the doctors conducted various tests and after arranging implants conducted surgery on 11.3.2021 and complainant was discharged on 20.3.2021 and total expenditure on the treatment was Rs. 6,96,908/-. The Medanta Hospital intimated the opposite parties No. 1 to 3 for cashless treatment but no approval was given by the opposite parties No. 1 to 3, thereafter the complainant applied for reimbursement but opposite party No. 3 repudiated the claim of the complainant vide letter dated 3.5.2021 by alleging that the claim of the complainant was not payable as per terms and conditions of the policy listed as Permanent Exclusion condition caused by suicide or substance abuse, Permanent exclusion the only ground was mentioned in the repudiation letter. The complainant alleged that the opposite parties had given false reasons behind the repudiation of the claim of the complainant.

13. On the other hand the opposite parties filed written version and taken various legal objections but they admitted the insurance policy and treatment taken by the complainant. The opposite parties alleged in the written version that the complainant through its treating hospital approached the answering opposite parties with the cashless request on 10.3.2021 where he was treated for carcinoma lower alveolus. The opposite parties further alleged that on receipt of cashless request the answering opposite parties sought certain additional information from the hospital vide query dated 10.3.2021. The opposite parties made a claim investigation basis the documents submitted alongwith the claim form and investigation, it came to the light that the complainant has been taking tobacco and alcohol since past 4 years as per the statement of the relative of the complainant Mr. Bimal Kumar. The ailment of complainant has direct correlation with his habit of tobacco intake, so the cashless request was denied vide letter dated 11.3.2021. Thereafter, the opposite parties received the reimbursement claim vide claim No. 91673167 and the same was rejected on the same ground vide letter dated 3.5.2021 as per terms and conditions of the policy. The letter stated that rejection reason as permanent exclusion condition caused by suicide or substance abuse. The opposite parties No. 1 to 3 further alleged in the written version that the complaint is not maintainable as the complainant himself violated the terms and conditions of the policy and there is no deficiency in service on the part of the opposite parties. 

14. The complainant has filed the rejoinder to the written version of the opposite parties No. 1 to 3 and denied all the averments mentioned in their written version. The complainant specifically denied in their rejoinder that the alleged Bimal Kumar is not relative of the complainant and complainant has no concern with the said person. 

15. After going through the pleadings and entire evidence produced by the complainant and the opposite parties it established that the policy and the treatment is not disputed in the present case. The only dispute in the present case is that whether the complainant has taking the tobacco and alcohol since 4 years or not or whether he concealed this fact from the opposite parties No. 1 to 3 while taking the alleged Health Insurance Policy. The learned counsel for the complainant argued that the complainant has not been taking any tobacco and alcohol as alleged by the opposite parties in their written version. The learned counsel for the complainant further argued that the statement of Bimal Kumar produced by the opposite parties in their evidence as Ex.OP-1.2.3/4 is false and baseless. The complainant has no concern with the alleged Bimal Kumar and he is not relative of the complainant. The learned counsel for the complainant further argued that it is mentioned in the said statement that “He does not smoke, he drink occasionally, two drinks of 30 ML each since last 4 years.” The learned counsel for the complainant further argued that it is clear from the said statement that the complainant has not taking tobacco and he is drinking occasionally two drinks of 30 ML which is not harmful and not comes under the definition of addiction. The complainant has produced the Nursing Adult Outpatient Assessment Sheet of Medanta Hospital Ex.C-4 in which the column of tobacco/alcohol/drug use was ticked as “No”. 

16. On the other had the learned counsel for the opposite parties argued that the complainant has violated the terms and conditions of the policy and he has been taking the tobacco and alcohol since last 4 years, therefore, the present complaint is not maintainable. The complainant concealed the material facts while taking the insurance policy. 

17. It is clear from the Nursing Adult Outpatient Assessment Sheet of Medanta Hospital Ex.C-4 that the social history (tobacco, alcohol, drug use) was ticked or answered by the complainant as “No”. The opposite parties produced Ex.OP-1.2.3/4 i.e. statement of Mr. Bimal Kumar, on the basis of said statement the opposite parties No. 1 to 3 repudiated the claim of the complainant. But on the perusal of the said statement it is clearly mentioned by said Bimal Kumar that “The complainant does not smoke, he drinks occasionally, two drinks of 30 ML since last 4 years”, which does not fall under the definition of addiction. Moreover, the complainant specifically denied in their rejoinder that said Bimal Kumar is not relative of the complainant and he has no concern with the complainant. 

18. From the above discussion, it proved that opposite parties failed to produce any evidence to prove, whether there is any relation of alleged Bimal Kumar with the complainant. On the other hand the complainant produced the Nursing Adult Outpatient Assessment Sheet of Medanta Hospital Ex.C-4 vide which he proved that he had not taken the tobacco and alcohol in the past. It established that claim was wrongly repudiated by the opposite parties No. 1 to 3 on unreasonable and unjustified grounds vide letter dated 3.5.2021 which is deficiency in service and unfair trade practice on the part of the opposite parties No. 1 to 3. 

19. On the perusal of the insurance policy it established that the complainant has taken the insurance policy for Rs. 5 lacs but he has paid Rs. 6,96,908/- to the Medanta Hospital vide bill Ex.C-8. 

20. In view of the above discussion, present complaint is partly allowed and opposite parties No. 1 to 3 are directed to pay an amount of Rs. 5,00,000/- to the complainant alongwith interest at the rate of 7% per annum from the date of filing of present complaint till actual realization as complainant has taken the Health Insurance policy of Rs. 5,00,000/- from the opposite parties No. 1 to 3. The opposite parties No. 1 to 3 further directed to pay Rs. 20,000/- to the complainant as compensation for mental tension and harassment and Rs. 5,500/- on account of litigation expenses. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order. The opposite parties No. 1 to 3 jointly and severally liable to comply with the above mentioned order. Copy of the order be supplied to the parties free of costs. File be consigned to its records after its due compliance.

ANNOUNCED IN THE OPEN COMMISSION:

        27th Day of January 2023 

 

            (Ashish Kumar Grover)

            President

              

(Urmila Kumari)

Member

 

(Navdeep Kumar Garg)

Member